The nurse has just completed a lymph node assessment on a healthy 40-year-old female patient. Which of the following is an expected finding?
Fixed lymph nodes
Lymph nodes that are large, firm, and fixed to the tissue
Nonpalpable lymph nodes
Rubbery, discrete, and mobile lymph nodes
The Correct Answer is C
A. Fixed lymph nodes suggest possible malignancy or infection and are not typical for a healthy individual.
B. Lymph nodes that are large, firm, and fixed to the tissue also suggest infection or malignancy and would be abnormal in a healthy patient.
C. Nonpalpable lymph nodes are a normal finding.
D. Rubbery, discrete, and mobile lymph nodes are indicative of a pathological process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Peripheral vascular disease involves issues with blood flow to the extremities but does not typically present with jugular vein distension or a gallop heart sound.
B. Fluid and electrolyte disturbances may affect heart rhythm and fluid balance but are less likely to present with these specific findings.
C. Heart failure is the most likely cause, as jugular vein distension and a third heart sound (S3 gallop) are common signs of heart failure, particularly when the heart cannot effectively pump blood.
D. Atrial-septal defect may cause heart murmurs or irregular rhythms but is not typically associated with jugular vein distension or an S3 gallop.
Correct Answer is B
Explanation
A. Assess the forearm and hand for infection would be relevant if the swollen lymph node were in the upper extremity, but the inguinal node would be more associated with a lower extremity infection.
B. Assess the lower extremities is the correct next step since the inguinal lymph nodes drain the lower body, including the legs and genital area.
C. Assess the dorsalis pedis pulses is not the next step, though it may be important if vascular concerns are suspected.
D. None of the above is incorrect because assessing the lower extremities is the next logical step.
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